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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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CQC Notifications Policy

1. Purpose

This policy sets out how {{org_field_name}} will meet its statutory duties to notify the Care Quality Commission (CQC) of specified changes, events and incidents relating to its regulated activities.

The principal notification requirements relevant to this policy arise under the Health and Social Care Act 2008, the Care Quality Commission (Registration) Regulations 2009, including Regulations 12 and 14 to 18 where applicable, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service will also have regard to current CQC statutory guidance issued under the Health and Social Care Act 2008.

Failure to make a statutory notification when required may constitute a breach of the registration requirements and, for specified provisions of the Care Quality Commission (Registration) Regulations 2009, may constitute an offence.

{{org_field_name}} will therefore ensure that reportable changes, events and incidents are identified promptly, escalated to the appropriate registered person, notified to CQC within the applicable statutory timescale and recorded accurately.

2. Scope

This policy applies to the Registered Manager, senior management, and all staff responsible for reporting incidents that require CQC notification. It ensures that any significant events affecting the health, safety, and welfare of people we support are promptly reported. The policy applies to all regulated activities carried out at {{org_field_name}}, including residential care, nursing care, and any specialist services provided.

3. Related Policies

• Incident Reporting and Management Policy – Guides staff on how to record and manage incidents before notifying CQC.
• Safeguarding Adults from Abuse and Improper Treatment Policy (CH13) – Ensures safeguarding concerns are properly reported and escalated.
• Duty of Candour Policy (CH35) – Promotes openness and honesty when things go wrong.
• Good Governance Policy (CH04) – Ensures compliance with regulatory requirements and internal governance procedures.
• Risk Management and Assessment Policy (CH18) – Provides a framework for identifying, assessing, and mitigating risks associated with care delivery.

4. Policy Statement

{{org_field_name}} is committed to full transparency and compliance with CQC regulations by promptly reporting required incidents and changes. Notifications ensure that the regulator is kept informed of any issues affecting the safety, quality, and effectiveness of care. We maintain a robust internal reporting system to support timely and accurate CQC notifications. All staff must understand their role in identifying and reporting events that require notification to the regulator.

5. When to Notify the CQC

The registered person must ensure that CQC is notified of all changes, events and incidents for which notification is required by the Care Quality Commission (Registration) Regulations 2009 or any other applicable registration requirement.

For this care home service, this includes the following where applicable.

Death of a person using the service

CQC must be notified without delay of the death of a person using the service where:

• the person died whilst services were being provided in the carrying on of a regulated activity; or
• the death has, or may have, resulted from the carrying on of a regulated activity.

Where a person was detained or liable to be detained under the Mental Health Act 1983, any separate statutory notification requirement relating to the person’s death must also be followed.

Serious injury

CQC must be notified without delay of an injury occurring whilst services are being provided in the carrying on of a regulated activity, or as a consequence of carrying on the regulated activity, where in the reasonable opinion of a health care professional the injury has resulted in:

• an impairment of the person’s sensory, motor or intellectual functions which is not likely to be temporary;
• a change to the structure of the person’s body;
• prolonged pain or prolonged psychological harm; or
• a shortening of the person’s life expectancy.

CQC must also be notified without delay where, in the reasonable opinion of a health care professional, an injury requires treatment by a health care professional in order to prevent the person’s death or to prevent one or more of the outcomes listed above.

For these purposes, prolonged pain or prolonged psychological harm means pain or harm experienced, or likely to be experienced, continuously for at least 28 days. An impairment is not temporary where it has lasted, or is likely to last, continuously for at least 28 days.

The decision about whether an injury meets the statutory threshold must be based on the circumstances and, where required by the regulation, the reasonable opinion of an appropriate health care professional. Hospital admission alone must not be used as the test of whether an injury is CQC-notifiable.

Abuse or allegations of abuse

CQC must be notified without delay of any abuse or allegation of abuse in relation to a person using the service where the incident occurs whilst services are being provided in the carrying on of a regulated activity or as a consequence of carrying on the regulated activity.

For the purposes of the CQC notification requirement, abuse includes:

• sexual abuse;
• physical or psychological ill-treatment;
• theft, misuse or misappropriation of money or property; and
• neglect or acts of omission which cause harm or place the person at risk of harm.

This notification requirement is separate from, and does not replace, the service’s duty to make safeguarding referrals or reports to the relevant local authority, police or other appropriate body.

Incidents reported to or investigated by the police

CQC must be notified without delay of any relevant incident which is reported to, or investigated by, the police where the incident occurs whilst services are being provided in the carrying on of the regulated activity or as a consequence of carrying on the regulated activity.

Where the incident has already resulted in a specific statutory notification, such as a death, serious injury or abuse notification, the current CQC instructions for the appropriate notification form must be followed so that unnecessary duplicate notifications are avoided.

Events that prevent or threaten the safe running of the service

CQC must be notified without delay of any event which prevents, or appears likely to threaten to prevent, {{org_field_name}} from continuing to carry on the regulated activity safely or in accordance with its registration requirements.

This includes, where the statutory threshold is met:

• insufficient numbers of suitably qualified, skilled and experienced staff to continue the regulated activity safely;
• interruption of electricity, gas, water or sewerage supplies to premises used for the regulated activity where the interruption lasts for more than a continuous period of 24 hours;
• physical damage to premises which has, or is likely to have, a detrimental effect on the treatment or care provided to people using the service; and
• failure or malfunction of fire alarms or other safety devices where the failure or malfunction lasts for more than a continuous period of 24 hours.

Other events, including fire, flooding, infectious-disease outbreaks, major equipment failure or other emergencies, must be notified to CQC under this provision where they prevent, or appear likely to threaten to prevent, the service from continuing the regulated activity safely or in accordance with its registration requirements.

An infectious-disease outbreak is not to be treated as a CQC statutory notification solely because an outbreak has occurred. Any separate legal or public-health reporting requirement must nevertheless be followed, and a CQC notification must be made where the circumstances meet another statutory notification threshold.

Deprivation of Liberty Safeguards and Court of Protection applications

Where applicable, CQC must be notified of the outcome of:

• a request made by the registered person to the supervisory body for a standard authorisation under Schedule A1 to the Mental Capacity Act 2005; or
• an application made to a court in relation to depriving a person using the service of their liberty under section 16(2)(a) of the Mental Capacity Act 2005.

The notification must be made once the outcome of the request or application is known or, if the request or application is withdrawn, at the point of withdrawal.

The notification must include the information required by the applicable regulation, including the date and nature of the request or application, whether it was preceded by an urgent authorisation where applicable, the outcome or reason for withdrawal, and the date of the outcome or withdrawal.

Absence of a registered manager or relevant registered individual for 28 days or more

Where the registered manager, or the service provider where the provider is personally in day-to-day charge of carrying on the regulated activity, proposes to be absent from carrying on or managing the regulated activity for a continuous period of 28 days or more, CQC must be notified in accordance with Regulation 14 of the Care Quality Commission (Registration) Regulations 2009.

The notification must include:

• the length or expected length of the absence;
• the reason for the absence;
• the arrangements for managing the regulated activity during the absence;
• the name, address and qualifications of the person who will be responsible for management during the absence; and
• where the registered manager is absent, the arrangements made or proposed for appointing another person to manage the regulated activity during the absence, including the proposed date by which the appointment is to be made.

CQC must also be notified when the relevant person returns to duty following an absence requiring notification.

Changes affecting the registered provider, registered manager or management of the regulated activity

The registered person must notify CQC, as soon as reasonably practicable, where any of the following applicable events takes place or is proposed to take place:

• a person other than the registered person carries on or manages the regulated activity;
• a registered person ceases to carry on or manage the regulated activity;
• the name of a registered person who is an individual changes;
• where the provider is a partnership, the membership of the partnership changes;
• where the provider is a body other than a partnership, the name or address of the body changes;
• where applicable, a director, secretary or other similar officer of the provider changes;
• the nominated individual changes; or
• a specified insolvency event occurs, including the appointment of a trustee in bankruptcy, receiver, manager, liquidator or provisional liquidator, as applicable to the legal form of the provider.

Where a registered manager is registering, cancelling their registration, adding or removing regulated activities or locations, or otherwise changing the activities or locations they manage, the current CQC registration and notification requirements must also be followed.

Statement of Purpose

{{org_field_name}} must keep its Statement of Purpose under review and revise it where appropriate.

Where the Statement of Purpose is revised, written details of the revision must be provided to CQC within 28 days of the revision.

Where a change to the service also requires a separate application to vary, add or remove a condition, regulated activity or location, the appropriate CQC registration application process must be completed in addition to notifying any change to the Statement of Purpose.

Mental Health Act notifications

Where {{org_field_name}} provides care to a person who is detained or liable to be detained under the Mental Health Act 1983, the registered person must comply with any applicable CQC statutory notification requirement concerning:

• the death of that person; or
• an unauthorised absence from the service.

These requirements must be applied according to Regulation 17 of the Care Quality Commission (Registration) Regulations 2009 and current CQC guidance.

6. Responsibilities for CQC Notifications

Registered Provider and Registered Person

The registered provider and any other registered person to whom the relevant regulation applies retain legal responsibility for ensuring compliance with statutory CQC notification requirements.

They must ensure that:

• effective systems are in place to identify events, incidents and changes that may require notification to CQC;
• notifications are made within the timescale required by the relevant regulation;
• the current CQC-prescribed form and submission method are used;
• information supplied to CQC is accurate, complete and not misleading;
• appropriate action is taken to protect people using the service and to comply with any separate safeguarding, police, health protection, coroner, local authority or other reporting requirement;
• evidence of the notification and any associated CQC reference or acknowledgement is retained; and
• failures, omissions or delays in statutory notification are identified, investigated and addressed.

Delegating the administrative completion or submission of a CQC notification to another competent member of staff does not remove the statutory responsibility of the registered person.

Registered Manager

The Registered Manager must:

• maintain oversight of incidents, events and changes occurring within the service which may require statutory notification;
• ensure that potential notifications are assessed promptly against the applicable statutory criteria;
• submit, or ensure the submission of, required notifications within the statutory timescale;
• ensure that the provider or nominated individual is informed promptly of significant statutory notifications where appropriate;
• maintain appropriate evidence of submitted notifications, acknowledgements and related correspondence;
• ensure that relevant incidents are investigated and appropriate corrective and preventive action is taken; and
• escalate immediately to the registered provider any uncertainty, failure or risk concerning compliance with a statutory notification requirement.

Where the Registered Manager is the registered person upon whom the particular notification duty falls, they retain their own legal responsibility for compliance with that duty.

Senior Staff and Team Leaders

Senior staff and team leaders must:

• immediately report to the Registered Manager, or the person deputising for them, any incident, event or change which may require notification to CQC;
• ensure that relevant contemporaneous records are completed accurately;
• preserve information and evidence required to support the notification and any subsequent investigation; and
• escalate the matter to the registered provider or other authorised senior person where the Registered Manager is unavailable and delay could result in a statutory deadline being missed.

All Staff

All staff must:

• report incidents, allegations, injuries, deaths, police involvement, service disruptions, safeguarding concerns and other significant events immediately through the service’s internal reporting arrangements;
• provide accurate information to those responsible for deciding whether a CQC notification is required;
• follow safeguarding and emergency procedures without waiting for completion of a CQC notification; and
• co-operate fully with investigations, reviews and regulatory follow-up arising from a notification.

7. How to Submit a CQC Notification

Statutory notifications must be made using the current form provided by CQC for the relevant type of notification where the regulations require a CQC-prescribed form.

The person submitting the notification must check the current CQC website or Provider Portal at the time of submission and use the submission method specified by CQC for that particular notification. Depending on the type of notification, this may include submission through the CQC Provider Portal or submission of the current CQC notification form by email.

An obsolete locally saved version of a CQC form must not be used where CQC has issued an updated form.

The person completing the notification must provide all information requested by the applicable CQC form. As relevant to the notification, this may include:

• the date, time and location of the event;
• the identity and relevant details of the person or people affected;
• a clear factual description of the incident, event or change;
• immediate action taken to protect people from harm;
• medical treatment or professional assessment obtained;
• safeguarding action taken;
• external agencies involved, including the police, local authority safeguarding team, health professionals or other relevant bodies;
• management and contingency arrangements;
• action taken or planned to reduce the risk of recurrence; and
• the details of the person submitting the notification.

Information supplied must be factual, accurate and sufficiently complete for CQC to understand the event and the action taken by the service. Where information is not yet available and the statutory notification cannot lawfully be delayed while it is obtained, the notification must be submitted within the statutory timescale using the information available at that time and updated where appropriate.

A copy or electronic record of the submitted notification, together with the submission date, CQC acknowledgement or reference number where issued, and relevant correspondence, must be retained in accordance with Section 9 of this policy.

Submitting a notification to CQC does not replace any separate statutory or professional requirement to report the matter to another body.

8. Reporting Timeframes

The statutory deadline applicable to the particular notification must always be followed. Internal investigation, management review or the gathering of additional information must not delay a notification beyond the statutory deadline.

The following requirements apply.

Deaths

A death which meets the criteria in Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 must be notified to CQC without delay.

There is no general statutory rule that permits the service to wait for up to 24 hours before making a reportable death notification.

Serious injuries

An injury which meets the statutory criteria in Regulation 18 must be notified to CQC without delay.

There is no general statutory 24-hour notification period for reportable serious injuries.

Abuse or allegations of abuse

Abuse or an allegation of abuse which meets the statutory criteria in Regulation 18 must be notified to CQC without delay.

Any required safeguarding referral to the relevant local authority, and any necessary police or emergency action, must be made in accordance with the applicable safeguarding arrangements and must not be delayed by the CQC notification process.

Incidents reported to or investigated by the police

A qualifying incident reported to or investigated by the police must be notified to CQC without delay.

Events preventing or threatening the safe running of the service

A qualifying event that prevents or appears likely to threaten to prevent the service from continuing to carry on the regulated activity safely or in accordance with its registration requirements must be notified to CQC without delay.

The specific statutory thresholds concerning interruptions to electricity, gas, water or sewerage and failure or malfunction of fire alarms or other safety devices include a continuous period exceeding 24 hours. This 24-hour threshold relates to whether those specified circumstances fall within the regulation; it must not be treated as a general 24-hour reporting deadline after an event has become notifiable.

Planned absence of 28 days or more

Where the registered manager, or the service provider where personally in day-to-day charge, proposes to be absent for a continuous period of 28 days or more, CQC must normally be notified no later than 28 days before the proposed absence begins, unless CQC agrees a shorter period.

Emergency absence of 28 days or more

Where the relevant absence arises because of an emergency, CQC must be notified within five working days of the occurrence of the absence, and the notification must contain the information required by Regulation 14.

Where a person has already been absent continuously for 28 days or more and the required notice has not been given, the registered person must notify CQC forthwith.

Return following a notified absence

CQC must be notified of the relevant registered person’s return to duty no later than seven working days after the date of return.

Changes affecting the provider, registered person or management of the service

Events or proposed events falling within Regulation 15 of the Care Quality Commission (Registration) Regulations 2009 must be notified as soon as it is reasonably practicable to do so.

Changes to the Statement of Purpose

Written details of any revision to the Statement of Purpose must be provided to CQC within 28 days of the revision.

Deprivation of liberty notifications

Where notification is required following a request for a standard authorisation or a relevant court application concerning deprivation of liberty, the notification must be made once the outcome of the request or application is known.

Where the request or application is withdrawn, the notification must be made at the point of withdrawal.

Other notification categories

Where another statutory CQC notification applies, including a notification relating to a person detained or liable to be detained under the Mental Health Act 1983, the specific timescale stated in the applicable regulation and current CQC notification guidance must be followed.

9. Maintaining Records of Notifications

{{org_field_name}} must maintain sufficient records to demonstrate that statutory CQC notification requirements have been identified, considered and complied with.

For each notification, the service must retain, as applicable:

• a copy or electronic record of the notification submitted to CQC;
• the date and method of submission;
• the CQC notification, enquiry, case or other acknowledgement reference where provided;
• relevant CQC correspondence and follow-up information;
• the records and evidence used to determine whether the event was notifiable;
• details of immediate protective or safeguarding action;
• investigation findings where an investigation was required;
• actions taken to reduce continuing or future risk; and
• evidence that other required agencies were informed.

Where a decision is made that a significant incident or event does not meet the statutory CQC notification threshold, the rationale for that decision should be documented where this is necessary to demonstrate effective governance and regulatory compliance.

Records must be accurate, complete, secure and accessible to authorised persons when required. They must be retained in accordance with the applicable legal requirements, the service’s records management and retention policy, data protection requirements and any applicable CQC requirements.

This policy does not impose a universal three-year retention period for CQC notifications. Any retention period used by {{org_field_name}} must be determined by the type of underlying record and the applicable statutory, regulatory and records-management requirements.

10. Staff Training and Awareness

• All staff must receive mandatory training on incident reporting and CQC notification requirements as part of their induction.
• The Registered Manager must ensure that team leaders and senior staff understand when and how to escalate reportable events.
• Regular refresher training and audits will ensure compliance with notification procedures.
• Staff must be informed of updates to CQC notification requirements and reporting best practices.

11. Policy Compliance and Continuous Improvement

• Regular internal audits will be conducted to review compliance with CQC reporting requirements and identify areas for improvement.
• Any missed or delayed notifications will be investigated to improve internal reporting systems.
• Feedback from CQC inspections will be used to enhance reporting efficiency and staff awareness.
• Learning from past notifications will be shared with staff to improve reporting culture and prevent recurring issues.

12. Policy Review

This policy will be reviewed annually or sooner if changes in CQC regulations, operational needs, or service improvements require an update. Any amendments will be communicated to all relevant staff to ensure continued compliance.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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